Vaping deaths and illness: What doctors need to know

An outbreak of vaping-related illness in the United States—especially among young adults and teenagers—has evoked concern and consternation among physicians and other members of the medical community, with some public health officials even declaring the epidemic of youth vaping a public health crisis.

Currently, the FDA and CDC, as well as local and state health departments, are investigating a spate of recent lung injuries and deaths among Americans who vape.

As of this writing, there have been 12 deaths due to vaping and 805 reported cases of vaping-related lung injuries in the United States, according to the CDC—with “hundreds” of new cases on the way.

Of the 373 cases examined by the CDC so far, 72% occurred in males, 67% occurred in people aged 18-34 years, and 16% occurred in people age 18 and younger. Most individuals with vaping-related illness reported a history of vaping tetrahydrocannabinol (THC) products; however, some reported previous use of e-cigarette products containing nicotine only.

As the investigation continues to determine the cause of the recent cluster of severe respiratory illnesses among e-cigarette users, here’s what you need to know.

Background

Electronic cigarettes go by many names, including e-cigarettes, vapes, vape pens, e-hookahs, and electronic nicotine delivery systems (ENDS). Vapes heat up a liquid to aerosol form, which is then inhaled into the lungs. This liquid consists of a variety of substances, additives, and active ingredients, including aldehydes, alcohol, nicotine, THC, and cannabinoid oils. Many substances found in vape liquid could contribute to the illness—but no single one has yet been found to cause it.

Moreover, the heating coils used in a vape pen or e-cigarette device could release harmful metals—such as manganese and zinc—into the inhaled aerosol when heated.

Symptoms

Not a lot of research has been published on the clinical effects of vaping. In July 2019, the Wisconsin Department of Health Services and the Illinois Department of Public Health partnered in a health investigation, and published their results in a preliminary report in The New England Journal of Medicine.

“Although the definitive cause of this cluster remains unknown, the severity of the illness and the recent increase in the incidence of this clinical syndrome indicates that these cases represent a new or newly recognized and worrisome cluster of pulmonary disease related to vaping,” wrote the investigators, led by Jennifer E. Layden, MD, PhD, chief medical officer and state epidemiologist, Illinois Department of Public Health.

The study included 53 people (83% men; median age: 19 years) who vaped within 90 days prior to symptom onset. In total, 100% of participants experienced generalized symptoms, 98% exhibited respiratory symptoms, and 81% experienced gastrointestinal symptoms. Moreover, all participants exhibited bilateral infiltrates on imaging. Of note, infiltrates and lack of pulmonary infection were case definitions for the study. In total, 94% of the study participants required hospitalization, with 32% requiring intubation and ventilation. One person died.

“Although the variety of imaging patterns suggests different mechanisms of injury, and more patterns will probably be reported, most of the patterns have basilar-predominant consolidation and ground-glass opacity, often with areas of lobular or subpleural sparing. Rapidly developing acute lung injuries (eg, acute eosinophilic pneumonia and diffuse alveolar damage) are associated with inhalational injuries and have overlapping pathological and imaging findings, and they have been reported to occur with vaping,” wrote Travis. S. Henry, MD, University of California, San Francisco, San Francisco, CA, and colleagues in an accompanying commentary.

Pneumonia-related damage

If you’ve been following the news, you’ve likely heard about lipoid pneumonia being associated with vaping. Lipoid pneumonia is an inflammatory process secondary to lipids within the alveoli, and results from the inhalation of hydrocarbons and oils, which are found in vaping liquid. Indeed, lipoid pneumonia has been detected in some of these cases, with evidence of lipid-laden alveolar macrophages obtained by bronchoalveolar lavage (BAL) and lipid staining. Notably, attenuation of the lung, which is a pathognomonic imaging finding for lipoid pneumonia, has not been observed.

Other patterns seen on imaging in patients who previously vaped correspond with acute eosinophilic pneumonia, organizing pneumonia, and diffuse alveolar damage, as well as variegated patterns. In some clinicopathologic investigations, hypersensitivity, giant-cell interstitial pneumonia, and diffuse alveolar hemorrhage were identified. Importantly, no specific antigen leading to hypersensitivity pneumonia has yet been elucidated in those who vape.

According to Dr. Layden and coauthors:

“Since no single product or substance has been associated with the illness, persons should consider not using e-cigarettes while this investigation is ongoing, especially those purchased from sources other than authorized retailers (eg, e-cigarette products with THC) and those modified in a manner not intended by the manufacturer. Adult smokers who are attempting to quit should consult with their health care provider and use proven treatments.”

Dr. Layden and fellow researchers also warned that vaping products should never be used by pregnant women, young adults, and nonsmokers.

Black market confounding

A black market for marijuana vapes is thriving, which is also scaring physicians and other public health stakeholders. The cartridges in these vapes can be tampered with adulterants, such as caffeine and alcohol, in order to make the product last longer. These black-market products are not only found on the streets but can also be purchased in smoke shops. One popular black-market product is called “Dark Vapes,” and many people with respiratory illness related to vaping have reported using this product.

Also, black-market vapes that have little or no manufacturer information are making it harder for investigators to find out what’s causing vaping-related illnesses.

Some anecdotal reports have cropped up of young people themselves tampering with the reservoirs found in vapes by adding caffeine, alcohol, vitamins, essential oils, and goodness knows what else. There are even YouTube videos that show users how to access and modify liquids and cartridges.

While obtaining a history of vape use, don’t forget to ask the patient whether he or she has purchased black-market vapes or vaped with products that were otherwise tampered with.

What to do

The CDC has issued guidance on how physicians and other healthcare professionals should deal with respiratory illness due to vaping. Here is their guidance in a nutshell:

1. Report vaping cases within the past 90 days to local or state health departments. This data will help the CDC in figuring out what exactly is causing respiratory illness in vape users.
   
   
2. Ask your patients about respiratory signs and symptoms.
   
   
3. Obtain a detailed history of vaping use, including substances used, devices uses, and where purchased.
   
   
4. Find out if the patient has any remaining product left for testing.
   
   
5. Pulmonary illness secondary to vaping is a diagnosis of exclusion. Thus, consider other infections, respiratory, and gastrointestinal differential diagnoses first and consult specialists as needed.
   
   
6. Corticosteroids may help on a case-by-case basis. Consult with a specialist if needed.
   
   
7. Consider BAL to detect lipoid pneumonia on a case-by-case basis. Consult with a specialist if needed.
   
   
8. If you end up doing a lung biopsy, make sure the sample is fresh and don’t forget to stain for lipids. Of note, routine processing of samples can affect lipid content.
   
   
9. Those who have received treatment for pulmonary disease secondary to e-cigarettes should receive regular follow-up to assess pulmonary function.

Finally, the CDC needs your help in solving the medical mystery of vaping-related illness. The agency recommends submitting samples for analysis. More information can be found here.